Provider Demographics
NPI:1265445449
Name:PETERSON, LESA DIONE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LESA
Middle Name:DIONE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 EAST 157TH
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110
Mailing Address - Country:US
Mailing Address - Phone:216-482-5523
Mailing Address - Fax:
Practice Address - Street 1:798 EAST 157TH
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-486-5523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN099875164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
2191588Medicare ID - Type Unspecified